Nursing Elites

1. A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention?

• A. Administering an antiviral agent
• B. Clustering care to conserve energy
• C. Offering oral fluids to promote hydration
• D. Providing an antitussive agent when necessary

Correct answer: B

Rationale: The priority intervention for a 3-month-old infant hospitalized with respiratory syncytial virus (RSV) is clustering care to conserve energy. Infants with RSV often struggle to breathe and require rest periods to recover. Clustering care involves organizing nursing activities to allow for rest intervals, reducing the infant's energy expenditure and aiding recovery. Administering antiviral agents is not the primary intervention for RSV since it is a viral infection, and antiviral medications may not be effective against RSV. While offering oral fluids is crucial for hydration, it may not be the priority when the infant is having respiratory difficulties. Providing an antitussive agent when necessary can help with coughing but is not the priority intervention for managing RSV in this scenario.

2. When planning the discharge of a child who had surgery for a congenital heart defect, what is an important aspect of the discharge teaching?

• A. Teaching the parents about signs of infection
• B. Providing instructions on wound care
• C. Scheduling follow-up appointments
• D. Explaining the use of prescribed medications

Correct answer: D

Rationale: Explaining the use of prescribed medications is crucial because it helps ensure proper management of the child’s condition after discharge. While teaching the parents about signs of infection and providing instructions on wound care are important aspects of postoperative care, they are not as critical as ensuring the correct understanding and administration of prescribed medications. Scheduling follow-up appointments is also important but does not directly impact the immediate post-discharge care and medication adherence.

3. At 7 AM, a nurse receives the information that an adolescent with diabetes has a 6:30 AM fasting blood glucose level of 180 mg/dL. What is the priority nursing action at this time?

• A. Encourage the adolescent to start exercising.
• B. Ask the adolescent to obtain an immediate glucometer reading.
• C. Inform the adolescent that a complex carbohydrate such as cheese should be eaten.
• D. Tell the adolescent that the prescribed dose of rapid acting insulin should be administered.

Correct answer: D

Rationale: Rapid acting insulin will help lower the elevated blood glucose level quickly.

4. A 13-year-old girl tells the nurse at the pediatric clinic that she took a pregnancy test and it was positive. She adds that her grandfather, with whom she, her younger sisters, and her mother live, has repeatedly molested her for the past 3 years. When the nurse asks the girl if she has told this to anyone, she replies, 'Yes, but my mother doesn’t believe me.' Legally, who should the nurse notify?

• A. Police regarding a possible sex crime
• B. Healthcare provider to confirm the pregnancy
• C. Child Protective Services for immediate intervention
• D. Girl’s mother about the positive pregnancy test result

Correct answer: C

Rationale: In this scenario, the nurse should notify Child Protective Services for immediate intervention. The girl disclosed ongoing sexual abuse by her grandfather, which is a serious concern requiring immediate protection and intervention by the appropriate authorities. Child Protective Services are trained to handle cases of child abuse and neglect, ensuring the safety and well-being of the child. While notifying the police about a possible sex crime is crucial, Child Protective Services should be the first point of contact in cases of suspected child abuse due to their specialized role. Confirming the pregnancy through a healthcare provider is not the priority at this moment, as ensuring the safety of the child is paramount. Informing the girl's mother about the positive test result is not appropriate given the lack of belief in the abuse disclosure and the potential risk to the child's safety.

5. A child with diabetes insipidus is being treated with vasopressin. The nurse would assess the child closely for signs and symptoms of which condition?

• A. Syndrome of inappropriate antidiuretic hormone (SIADH)
• B. Thyroid storm
• C. Cushing syndrome
• D. Vitamin D toxicity

Correct answer: A

Rationale: When a child with diabetes insipidus is treated with vasopressin, the nurse should closely monitor for signs and symptoms of Syndrome of Inappropriate Antidiuretic Hormone (SIADH). Vasopressin, also known as antidiuretic hormone, helps retain water in the body. Excessive vasopressin administration can lead to water retention, dilutional hyponatremia, and potentially result in SIADH. Choices B, C, and D are incorrect because they are not directly associated with the use of vasopressin in treating diabetes insipidus.

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